MetroPlus Gold Formulary Summary - MetroPlus Health Plan
MetroPlus Gold Formulary Summary - MetroPlus Health Plan
MetroPlus Gold Formulary Summary - MetroPlus Health Plan
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<strong>MetroPlus</strong> <strong>Gold</strong> <strong>Plan</strong> with Rider<br />
Drug Coverage Rules<br />
As of July 2010<br />
All Rx Products are covered without restriction unless otherwise defined below.<br />
Exclusions<br />
Fertility Agents<br />
Erectile Dysfunction Meds<br />
Rx Omeprazole 20 & 40mg (OTC Prilosec Covered)<br />
Immunizations<br />
OTCs (except Acne products containing Benzoyl Peroxide, Benzoyl Peroxide with Urea, Salicylic Acid & Sulfur; OTC<br />
Prilosec, Lactic Acid products, Respiratory Therapy Supplies, GI/GU Ostomy & Irrigation Supplies, Diabetic Supplies,<br />
Bandages/Dressings, Elastic Bandages/Supports, Eye Patches, Thermometer Sheaths, Alcohol Swabs, Rubber Goods)<br />
<strong>Plan</strong>axis<br />
Nutritional Substitutes<br />
Yohimbine<br />
Cosmetic Alteration Drugs<br />
Mulitvitamins with Flouride or Iron<br />
Mulivitamines<br />
Weight Loss<br />
Prior Authorizations:<br />
Retinoids (cover through age 26, then PA req.)<br />
Synagis<br />
Lupron<br />
Growth Hormones<br />
Pexeva<br />
Glucose Polymer Powder<br />
Med Chain Triglyceride Oil<br />
Gamma-Aminobutyric Acid<br />
Nutritional Supplements<br />
Coenzyme Q<br />
Botox<br />
Quantity Limits:<br />
Amerge (naratriptan)<br />
Axert (almotriptan)<br />
Frova (frovatriptan)<br />
Imitrex (sumatriptan) injection<br />
Imitrex (sumatriptan) injection kit<br />
Imitrex (sumatriptan) nasal spray<br />
Imitrex (sumatriptan) tablets<br />
Maxalt (rizatriptan)<br />
Migranal (dihydroergotamine mesylate)<br />
Relpax (eletriptan)<br />
Zomig (zolmitriptan) nasal spray<br />
Migraine Agents<br />
9/30 days<br />
12/30 days<br />
9/30 days<br />
5ml/10 syringes/<br />
30 days<br />
4 boxes/8 syringes/<br />
30 days<br />
12 sprays/30 days<br />
9/30 days<br />
9/30 days<br />
8/30 days<br />
6/30 days<br />
6/30 days
Antiulcer Medications<br />
Blood Glucose Meters<br />
2 Year<br />
Smoking Cessation<br />
3 fills per year<br />
Sedative Hypnotics 15 per 30<br />
Step Therapy:<br />
Step Therapy for Non Sedating Antihistamine<br />
(Clarinex, Allegra, Zyrtec and all D formularions )<br />
Step Therapy for Spiriva<br />
Must try and fail loratadine in the past 180 days prior<br />
to filling Clarinex & (D), Allegra/fexofenadine & (D),<br />
Zyrtec/Cetirizine & (D)<br />
Must try/fail generic Ipratropium Bromide
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